Provider Demographics
NPI:1780730788
Name:CUNNINGHAM, KELLY E (LISW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:E
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22993 CENTER RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-3630
Mailing Address - Country:US
Mailing Address - Phone:440-835-4882
Mailing Address - Fax:
Practice Address - Street 1:20525 DETROIT RD
Practice Address - Street 2:SUITE 6
Practice Address - City:ROCKY RIVER
Practice Address - State:OH
Practice Address - Zip Code:44116-2444
Practice Address - Country:US
Practice Address - Phone:440-409-5486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI 00083011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical